Cost-effectiveness of mechanical thrombectomy versus intravenous thrombolysis in acute ischemic stroke: a systematic review

Mechanical thrombectomy (MT) is a proven treatment for acute ischemic stroke (AIS), yet its cost-effectiveness across global settings remains unclear. This systematic review synthesizes cost-effectiveness evidence and introduces a framework for evaluating MT across different health systems. Following PRISMA 2020 guidelines, comprehensive searches were conducted across four major databases to identify full economic evaluations comparing MT with intravenous thrombolysis (IVT). Methodological quality was assessed using the Quality of Health Economic Studies (QHES) checklist, and findings were synthesized qualitatively. Incremental cost-effectiveness ratios (ICERs) were converted to 2024 US dollars. Studies were categorized by income level, modeling approach, perspective, and real-world vs. trial-based data. Of 4550 records screened, 56 met the inclusion criteria. The mean QHES score was 0.83, indicating high quality. MT was consistently cost-effective or dominant across diverse healthcare contexts. Sensitivity analyses indicated that ICER variability was primarily influenced by device costs, patient age, time horizon, acute care costs, and input data used for functional outcomes and utility weights. MT is a high-value intervention, but its cost-effectiveness is context-dependent. Our classification framework supports localized decision-making. Future research should address geographic inequities in existing economic evaluations and expand evidence from low-resource settings and also integrate real-world data. PROSPERO (CRD42024496552).